Strategies to help patients break the chains of tobacco addiction
Evidence-based treatments can help patients quit despite psychiatric illness
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You are treating Mr. P, age 34, for schizoaffective disorder. He smokes 1 pack of cigarettes per day and has smoked for approximately 17 years. He has tried to stop but never has been able to quit for more than a few weeks. He reveals whenever he tries to quit, he starts feeling extremely lethargic and “depressed” and resumes smoking to prevent these symptoms from worsening. However, Mr. P expresses some interest in trying to quit again and asks whether any medications could prevent him from becoming depressed while he tries to quit.
Cigarette smoking is overrepresented and undertreated among individuals with psychiatric illness, in part because of the largely unfounded belief held by some patients and clinicians that smoking cessation might worsen psychiatric symptoms. In this article, we argue this challenge can be overcome and psychiatrists and other mental health professionals can and should help their patients reap the innumerable benefits of quitting smoking. We discuss:
- the short- and long-term effects of smoking cessation
- evidence-based treatment guidelines for working with motivated and unmotivated smokers
- unique issues that may arise when treating smokers who have psychiatric disorders.
Quitting: Profound benefits
Quitting smoking has substantial benefits beginning within minutes after taking the last puff. Some of the benefits that occur within the first few days of quitting include:
- decreased blood pressure and pulse rate
- improved circulation
- improved ability to smell and taste
- easier breathing.
Longer-term smoking abstinence drastically reduces risk of heart attack, stroke, cancer, respiratory disease, and a host of other illnesses that affect—and kill—individuals with psychiatric disorders several decades earlier than their counterparts in the general population.1 There also are financial benefits to quitting; using the 2009 national average of $5.33 per pack, a 1-pack-per-day smoker who quits would save >$150 per month, which accounts for only the direct cost of cigarettes.2
Although the beneficial effects of quitting smoking are profound and far-reaching, in the short-term they are counterbalanced by nicotine withdrawal symptoms—including restlessness, irritability, depressed mood, concentration problems, and increased appetite/weight gain—that are formidable distractions from the positive aspects of quitting. Additionally, nicotine withdrawal symptoms tend to be more severe in smokers who have a psychiatric disorder.3 Fortunately, there are effective, evidence-based methods of reducing withdrawal symptoms and helping smokers cope with these and other challenges of quitting.
Combined treatment is best
Current treatment guidelines4 suggest all smokers should be offered pharmacotherapy and counseling to aid quitting because this combined approach has the highest success rate (Algorithm). Table 1 4 provides information about dosing, efficacy, and side effect profile of each of the 7 FDA-approved medications for smoking cessation. Using any of the approved medications at least doubles the odds of successful quitting compared with placebo.4 These pharmacotherapies can reduce or prevent nicotine withdrawal symptoms and—at least in the case of bupropion and varenicline—decrease reinforcement from smoking, thereby lowering the likelihood a lapse (ie, smoking ≥1 cigarettes without returning to regular smoking) will develop into a full-blown relapse (ie, return to regular smoking).
Algorithm: Tobacco cessation treatment for psychiatric patients
Source: Adapted from reference 4 Medication selection depends on many factors, including:
- the patient’s psychiatric illness
- her/his prior response to smoking cessation pharmacotherapies
- concomitant psychiatric medications
- patient preference.5
Placebo-controlled trials of smoking cessation aids in psychiatrically ill patients are limited, but several studies of smokers with a history of major depression indicate treatment with bupropion SR or nortriptyline is effective.6 Similarly, although relapse rates generally are higher in patients with schizophrenia compared with non-mentally ill smokers, nicotine replacement therapy and bupropion SR are more effective than placebo in patients with this disorder.7,8 When we prescribe these treatments, we tend to extend the duration of treatment beyond those described in Table 1 ,4 and to use combined treatments (eg, a transdermal patch with a shorter-acting gum or lozenge preparation) to better target the marked withdrawal symptoms more severely nicotine-dependent patients frequently experience.
First-line pharmacotherapies for smoking cessation
Efficacy (OR, % abstinent at 6 mos. [with 95% CI])
Contraindications (C) and precautions (P)
Common side effects
Days 1-3: 150 mg/d
2.0 (1.8-2.2), 24% (22%-26%)
C: Eating disorders, seizure history, taking bupropion, MAOI in past 2 weeks P: Pregnancy, cardiovascular disease, warning for emergent psychiatric symptoms
Insomnia, dry mouth
Days 1-3: 0.5 mg/d
3.1 (2.5-3.8), 33% (29%-38%)
P: Warning for emergent psychiatric symptoms
Nausea, sleep problems, abnormal dreams
Nicotine replacement therapies
1 piece every 1-2 hours for 6-12 weeks
1.5 (1.2-1.7), 19% (17%-22%)
P: Pregnancy, recent myocardial infarction, serious arrhythmia, unstable angina
Mouth soreness, hiccups, dyspepsia
6-16 cartridges/d, up to 6 months
2.1 (1.5-2.9), 25% (19%-32%)
Same as above
Mouth/throat irritation, coughing, rhinitis
9-20 lozenges/d, up to 12 weeks
Same as above
Nausea, hiccups, heartburn
Nicotine nasal spray
1-2 doses/hour, 8-40 doses/d for 3-6 months
2.3 (1.7-3.0), 27% (22%-33%)
C: Severe reactive airway disease P: Same as above
Nasal irritation, higher risk of dependency
1 patch/d, step-down dosing over 8 weeks
1.9 (1.7-2.2) 23% (21%-26%)
P: Same as above
Skin reactions, sleep problems, abnormal dreams
aStead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2008;1:CD000146.
Counseling. All smokers should be provided with brief interventions consistent with the 5 A’s—Ask, Advise, Assess, Assist, and Arrange (Table 2).4 For smokers who are not motivated to quit, the recommended approach follows the principles of the 5 R’s—Relevance, Risks, Rewards, Roadblocks, and Repetition (Table 3).4 Smokers who are motivated to quit and willing to participate in more intensive treatment may be offered face-to-face individual or group counseling (depending upon availability) or referred to a telephone quit line (see Related Resources). Intensive treatments such as these typically provide social support and assistance overcoming barriers to cessation and developing skills to initiate and maintain abstinence (eg, coping with a lapse or handling cravings, identifying and avoiding high-risk situations for smoking). As a general rule, greater intensity of counseling is associated with a greater likelihood of quitting.4
The 5 A’s of tobacco treatment
Systematically inquire about tobacco use
“Do you currently use, or have you ever used, tobacco products?”
Counsel all tobacco users to quit in a clear, strong, and personalized manner
“I think it is very important for you quit smoking to keep your breathing problems from getting any worse”
Determine the tobacco user’s willingness to make a quit attempt
“What do you think? Are you ready to quit?”
Offer or refer to treatment/support (if ready to quit; if not ready, see Table 3 for recommended interventions)
“I’m here to help you with this. Let me start by letting you know about the many options available to help you quit”
Plan for follow-up contacts (at least 1, preferably within 1 week of the quit date)
“I would like to give you a call within the next week to see how you did with your quit date. Would that be OK with you?”
Source: Adapted from reference 4
The 5 R’s: Principles of interventions for smokers not ready to quit
Why is quitting smoking personally relevant?
“You’ve told me your kids sometimes make comments to you about quitting smoking. How does that affect you?”
What are the negative consequences of smoking?
“What don’t you like about smoking? What problems have you had from smoking?”
What are the benefits of quitting smoking?
“Can you think of anything that would be good about quitting? Tell me about that”
What are the barriers to quitting?
“What worries do you have about trying to quit? What happened the last time you tried to quit smoking?”
Message repeated at every visit
“I know we have talked about quitting smoking before, but things may have changed since then. I also think that this is such an important issue we should keep it on the table for discussion. What do you think?”
Source: Adapted from reference 4
Q&A about treatment
How effective are smoking cessation interventions for individuals with psychiatric disorders? Several studies have demonstrated, on any given quit attempt, smokers with psychiatric or substance use disorders can be as successful as smokers without these disorders.9-11 In fact, quit rates as high as approximately 70% for end-of-treatment11 and 30% for 6-month follow-up10 have been reported. Of course, effectiveness varies by type and intensity of treatment as well as by individual characteristics of the smoker. Smokers with psychiatric disorders may fare better with more intensive interventions than briefer ones,12,13 and factors such as high levels of nicotine dependence and exposure to smoking environments—both of which are characteristic of smokers with serious mental illness—can negatively impact treatment outcomes.4
Should the nature of the psychiatric disorder(s) guide decisions about the optimal pharmacotherapy or counseling approach? There have been numerous attempts to investigate the effectiveness of targeted interventions for particular subgroups of smokers with psychiatric disorders, including:
- studies of the efficacy of the antidepressants bupropion14 and nortriptyline15 as well as cognitive-behavioral therapy-based mood management counseling16 for depressed smokers
- integrative treatment approaches for smokers with posttraumatic stress disorder (PTSD)17
- group counseling designed specifically for smokers with schizophrenia.18,19
Although more research is needed and there have been some promising early results (eg, McFall et al17), current literature does not provide consistent evidence supporting treatment matching solely on the basis of the psychiatric disorder. Rather, patient preference, safety considerations (eg, use of medications in children/adolescents, pregnant women), medication side effect profiles, prior experience with the treatment approach, and cost/availability of treatment should guide development of the treatment plan. When results from placebo-controlled trials are available for subgroups of patients (eg, those with a history of major depression), consider this information when selecting a pharmacologic smoking cessation aid.
What is the risk of psychiatric symptoms worsening as a result of quitting smoking? Little research on this topic is available because more often than not, smokers with psychiatric disorders are excluded from tobacco treatment studies. However, research examining psychiatric status changes among recent quitters with schizophrenia,20,21 depression,22,23 PTSD,17 and substance use disorders24 suggests smoking cessation does not worsen symptoms of these disorders, and may be associated with symptom improvement.17 Nonetheless, driven largely by anecdotal evidence, the misconception that smoking cessation worsens psychiatric symptoms remains a substantial barrier to treatment.
Mr. P’s case is an example of how not probing about the nature of psychiatric complaints can be problematic. Mr. P reported what on first glance appeared to be a worsening of psychiatric symptoms starting when he stopped smoking and resolved when he resumed smoking. However, without gathering additional information about these events, we cannot conclude stopping smoking caused his psychiatric symptoms to worsen. Other potential explanations include nicotine withdrawal symptoms, side effects of smoking cessation medications, an increase in levels of psychotropic medications for which metabolism is affected by tobacco smoke, or the natural course of his mood disorder. The timing of the onset and offset of symptoms seems to argue against Mr. P’s symptoms reflecting the natural course of his mood disorder, but the other 3 explanations remain plausible.